|
LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)
|
Facility
|
OP
|
$40,697.48
|
|
|
Service Code
|
CPT 58573
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$7,795.33 |
| Max. Negotiated Rate |
$40,697.48 |
| Rate for Payer: Aetna Managed Medicare |
$10,174.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$18,649.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$18,649.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$17,230.00
|
| Rate for Payer: Anthem Medicare Advantage |
$10,174.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$10,174.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$10,174.37
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$10,174.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,795.33
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$10,174.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$37,848.66
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$10,174.37
|
| Rate for Payer: Independent Care Health Plan Medicare |
$10,174.37
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$10,174.37
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$10,174.37
|
| Rate for Payer: NAPHCARE Commercial |
$15,261.56
|
| Rate for Payer: Quartz Medicare Advantage |
$10,174.37
|
| Rate for Payer: The Alliance Commercial |
$40,697.48
|
| Rate for Payer: United Healthcare Medicare Advantage |
$10,174.37
|
| Rate for Payer: United Healthcare PPO |
$9,596.00
|
| Rate for Payer: Wellcare Medicare |
$10,174.37
|
|
|
LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)
|
Facility
|
OP
|
$40,697.48
|
|
|
Service Code
|
CPT 58552
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$9,596.00 |
| Max. Negotiated Rate |
$40,697.48 |
| Rate for Payer: Aetna Managed Medicare |
$10,174.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$18,649.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$18,649.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$17,230.00
|
| Rate for Payer: Anthem Medicare Advantage |
$10,174.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$10,174.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$10,174.37
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$10,174.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,009.73
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$10,174.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$37,848.66
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$10,174.37
|
| Rate for Payer: Independent Care Health Plan Medicare |
$10,174.37
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$10,174.37
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$10,174.37
|
| Rate for Payer: NAPHCARE Commercial |
$15,261.56
|
| Rate for Payer: Quartz Medicare Advantage |
$10,174.37
|
| Rate for Payer: The Alliance Commercial |
$40,697.48
|
| Rate for Payer: United Healthcare Medicare Advantage |
$10,174.37
|
| Rate for Payer: United Healthcare PPO |
$9,596.00
|
| Rate for Payer: Wellcare Medicare |
$10,174.37
|
|
|
LAPAROTOMY, GENERAL, EXPLORATORY
|
Facility
|
OP
|
$4,803.00
|
|
| Hospital Charge Code |
2960038
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,344.84 |
| Max. Negotiated Rate |
$19,212.00 |
| Rate for Payer: Aetna Commercial |
$4,322.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,130.58
|
| Rate for Payer: Aetna Managed Medicare |
$1,344.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,121.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,401.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,305.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,545.59
|
| Rate for Payer: Cash Price |
$1,440.90
|
| Rate for Payer: Cigna Commercial |
$4,418.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,687.76
|
| Rate for Payer: Health EOS Commercial |
$4,274.67
|
| Rate for Payer: HFN Commercial |
$4,418.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,602.25
|
| Rate for Payer: Multiplan Commercial |
$3,842.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,881.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,418.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,353.47
|
| Rate for Payer: Quartz Commercial |
$3,121.95
|
| Rate for Payer: Quartz Medicare Advantage |
$2,881.80
|
| Rate for Payer: The Alliance Commercial |
$19,212.00
|
| Rate for Payer: WEA Trust Commercial |
$2,641.65
|
| Rate for Payer: WPS Commercial |
$3,557.58
|
|
|
LAPAROTOMY, GENERAL, EXPLORATORY
|
Facility
|
IP
|
$4,803.00
|
|
| Hospital Charge Code |
2960038
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,353.47 |
| Max. Negotiated Rate |
$4,418.76 |
| Rate for Payer: Aetna Commercial |
$4,322.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,130.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,545.59
|
| Rate for Payer: Cash Price |
$1,440.90
|
| Rate for Payer: Cigna Commercial |
$4,418.76
|
| Rate for Payer: Health EOS Commercial |
$4,274.67
|
| Rate for Payer: HFN Commercial |
$4,418.76
|
| Rate for Payer: Multiplan Commercial |
$3,842.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,881.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,418.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,353.47
|
| Rate for Payer: Quartz Commercial |
$2,881.80
|
| Rate for Payer: WEA Trust Commercial |
$2,641.65
|
| Rate for Payer: WPS Commercial |
$3,557.58
|
|
|
LAPAROTOMY, GYNE, EXPLORATORY
|
Facility
|
IP
|
$4,803.00
|
|
| Hospital Charge Code |
2960039
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,353.47 |
| Max. Negotiated Rate |
$4,418.76 |
| Rate for Payer: Aetna Commercial |
$4,322.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,130.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,545.59
|
| Rate for Payer: Cash Price |
$1,440.90
|
| Rate for Payer: Cigna Commercial |
$4,418.76
|
| Rate for Payer: Health EOS Commercial |
$4,274.67
|
| Rate for Payer: HFN Commercial |
$4,418.76
|
| Rate for Payer: Multiplan Commercial |
$3,842.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,881.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,418.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,353.47
|
| Rate for Payer: Quartz Commercial |
$2,881.80
|
| Rate for Payer: WEA Trust Commercial |
$2,641.65
|
| Rate for Payer: WPS Commercial |
$3,557.58
|
|
|
LAPAROTOMY, GYNE, EXPLORATORY
|
Facility
|
OP
|
$4,803.00
|
|
| Hospital Charge Code |
2960039
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,344.84 |
| Max. Negotiated Rate |
$19,212.00 |
| Rate for Payer: Aetna Commercial |
$4,322.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,130.58
|
| Rate for Payer: Aetna Managed Medicare |
$1,344.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,121.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,401.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,305.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,545.59
|
| Rate for Payer: Cash Price |
$1,440.90
|
| Rate for Payer: Cigna Commercial |
$4,418.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,687.76
|
| Rate for Payer: Health EOS Commercial |
$4,274.67
|
| Rate for Payer: HFN Commercial |
$4,418.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,602.25
|
| Rate for Payer: Multiplan Commercial |
$3,842.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,881.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,418.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,353.47
|
| Rate for Payer: Quartz Commercial |
$3,121.95
|
| Rate for Payer: Quartz Medicare Advantage |
$2,881.80
|
| Rate for Payer: The Alliance Commercial |
$19,212.00
|
| Rate for Payer: WEA Trust Commercial |
$2,641.65
|
| Rate for Payer: WPS Commercial |
$3,557.58
|
|
|
LAP-BAND PORT ADJUSTMENT
|
Facility
|
OP
|
$1,006.00
|
|
| Hospital Charge Code |
2960175
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$281.68 |
| Max. Negotiated Rate |
$4,024.00 |
| Rate for Payer: Aetna Commercial |
$905.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$865.16
|
| Rate for Payer: Aetna Managed Medicare |
$281.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$653.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$503.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$482.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$533.18
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$925.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$562.96
|
| Rate for Payer: Health EOS Commercial |
$895.34
|
| Rate for Payer: HFN Commercial |
$925.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$754.50
|
| Rate for Payer: Multiplan Commercial |
$804.80
|
| Rate for Payer: NAPHCARE Commercial |
$603.60
|
| Rate for Payer: Preferred Network Access Commercial |
$925.52
|
| Rate for Payer: Quartz Beloit One Network |
$492.94
|
| Rate for Payer: Quartz Commercial |
$653.90
|
| Rate for Payer: Quartz Medicare Advantage |
$603.60
|
| Rate for Payer: The Alliance Commercial |
$4,024.00
|
| Rate for Payer: WEA Trust Commercial |
$553.30
|
| Rate for Payer: WPS Commercial |
$745.14
|
|
|
LAP-BAND PORT ADJUSTMENT
|
Facility
|
IP
|
$1,006.00
|
|
| Hospital Charge Code |
2960175
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$492.94 |
| Max. Negotiated Rate |
$925.52 |
| Rate for Payer: Aetna Commercial |
$905.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$865.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$533.18
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$925.52
|
| Rate for Payer: Health EOS Commercial |
$895.34
|
| Rate for Payer: HFN Commercial |
$925.52
|
| Rate for Payer: Multiplan Commercial |
$804.80
|
| Rate for Payer: NAPHCARE Commercial |
$603.60
|
| Rate for Payer: Preferred Network Access Commercial |
$925.52
|
| Rate for Payer: Quartz Beloit One Network |
$492.94
|
| Rate for Payer: Quartz Commercial |
$603.60
|
| Rate for Payer: WEA Trust Commercial |
$553.30
|
| Rate for Payer: WPS Commercial |
$745.14
|
|
|
LAP, MOBIL SPLENIC FL ADD-ON 44213
|
Professional
|
Both
|
$1,349.00
|
|
|
Service Code
|
CPT 44213
|
| Hospital Charge Code |
3014750
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$163.36 |
| Max. Negotiated Rate |
$1,281.55 |
| Rate for Payer: Aetna Commercial |
$1,281.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,160.14
|
| Rate for Payer: Cash Price |
$404.70
|
| Rate for Payer: Cash Price |
$404.70
|
| Rate for Payer: Cash Price |
$404.70
|
| Rate for Payer: Cigna Commercial |
$1,281.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$163.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$809.40
|
| Rate for Payer: Health EOS Commercial |
$1,227.59
|
| Rate for Payer: HFN Commercial |
$1,281.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$605.92
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$605.92
|
| Rate for Payer: Multiplan Commercial |
$1,079.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,281.55
|
| Rate for Payer: Quartz Beloit One Network |
$593.56
|
| Rate for Payer: Quartz Commercial |
$768.93
|
| Rate for Payer: The Alliance Commercial |
$674.50
|
| Rate for Payer: United Healthcare Medicaid |
$163.36
|
| Rate for Payer: WEA Trust Commercial |
$741.95
|
| Rate for Payer: WPS Commercial |
$999.20
|
|
|
LAPS COLECTOMY PRTLl W/RMVL TERMINAL ILEUM, ADDL 4420522
|
Professional
|
Both
|
$8,009.00
|
|
|
Service Code
|
CPT 44205 22
|
| Hospital Charge Code |
6171908
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$934.56 |
| Max. Negotiated Rate |
$7,608.55 |
| Rate for Payer: Aetna Commercial |
$7,608.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,887.74
|
| Rate for Payer: Cash Price |
$2,402.70
|
| Rate for Payer: Cash Price |
$2,402.70
|
| Rate for Payer: Cash Price |
$2,402.70
|
| Rate for Payer: Cigna Commercial |
$7,608.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$934.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,805.40
|
| Rate for Payer: Health EOS Commercial |
$7,288.19
|
| Rate for Payer: HFN Commercial |
$7,608.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,344.23
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$4,344.23
|
| Rate for Payer: Multiplan Commercial |
$6,407.20
|
| Rate for Payer: Preferred Network Access Commercial |
$7,608.55
|
| Rate for Payer: Quartz Beloit One Network |
$3,523.96
|
| Rate for Payer: Quartz Commercial |
$4,565.13
|
| Rate for Payer: The Alliance Commercial |
$4,004.50
|
| Rate for Payer: United Healthcare Medicaid |
$934.56
|
| Rate for Payer: WEA Trust Commercial |
$4,404.95
|
| Rate for Payer: WPS Commercial |
$5,932.27
|
|
|
Laps Colectomy Prtl W/rmvl Terminal Ileum 44205
|
Professional
|
Both
|
$6,674.00
|
|
|
Service Code
|
CPT 44205
|
| Hospital Charge Code |
4624608
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$934.56 |
| Max. Negotiated Rate |
$6,340.30 |
| Rate for Payer: Aetna Commercial |
$6,340.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,739.64
|
| Rate for Payer: Cash Price |
$2,002.20
|
| Rate for Payer: Cash Price |
$2,002.20
|
| Rate for Payer: Cash Price |
$2,002.20
|
| Rate for Payer: Cigna Commercial |
$6,340.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$934.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,004.40
|
| Rate for Payer: Health EOS Commercial |
$6,073.34
|
| Rate for Payer: HFN Commercial |
$6,340.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,344.23
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$4,344.23
|
| Rate for Payer: Multiplan Commercial |
$5,339.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6,340.30
|
| Rate for Payer: Quartz Beloit One Network |
$2,936.56
|
| Rate for Payer: Quartz Commercial |
$3,804.18
|
| Rate for Payer: The Alliance Commercial |
$3,337.00
|
| Rate for Payer: United Healthcare Medicaid |
$934.56
|
| Rate for Payer: WEA Trust Commercial |
$3,670.70
|
| Rate for Payer: WPS Commercial |
$4,943.43
|
|
|
LAPS MOBLJ SPLENIC FLXR W/PRTL COLECTOMY- ADD-ON, ADDTL SVCS 4421322
|
Professional
|
Both
|
$1,618.00
|
|
|
Service Code
|
CPT 44213 22
|
| Hospital Charge Code |
6174919
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$163.36 |
| Max. Negotiated Rate |
$1,537.10 |
| Rate for Payer: Aetna Commercial |
$1,537.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,391.48
|
| Rate for Payer: Cash Price |
$485.40
|
| Rate for Payer: Cash Price |
$485.40
|
| Rate for Payer: Cash Price |
$485.40
|
| Rate for Payer: Cigna Commercial |
$1,537.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$163.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$970.80
|
| Rate for Payer: Health EOS Commercial |
$1,472.38
|
| Rate for Payer: HFN Commercial |
$1,537.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$605.92
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$605.92
|
| Rate for Payer: Multiplan Commercial |
$1,294.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,537.10
|
| Rate for Payer: Quartz Beloit One Network |
$711.92
|
| Rate for Payer: Quartz Commercial |
$922.26
|
| Rate for Payer: The Alliance Commercial |
$809.00
|
| Rate for Payer: United Healthcare Medicaid |
$163.36
|
| Rate for Payer: WEA Trust Commercial |
$889.90
|
| Rate for Payer: WPS Commercial |
$1,198.45
|
|
|
Large black foam
|
Facility
|
OP
|
$976.00
|
|
| Hospital Charge Code |
3006912
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$273.28 |
| Max. Negotiated Rate |
$3,904.00 |
| Rate for Payer: Aetna Commercial |
$878.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$839.36
|
| Rate for Payer: Aetna Managed Medicare |
$273.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$634.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$488.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$468.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$517.28
|
| Rate for Payer: Cash Price |
$292.80
|
| Rate for Payer: Cigna Commercial |
$897.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$546.17
|
| Rate for Payer: Health EOS Commercial |
$868.64
|
| Rate for Payer: HFN Commercial |
$897.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$732.00
|
| Rate for Payer: Multiplan Commercial |
$780.80
|
| Rate for Payer: NAPHCARE Commercial |
$585.60
|
| Rate for Payer: Preferred Network Access Commercial |
$897.92
|
| Rate for Payer: Quartz Beloit One Network |
$478.24
|
| Rate for Payer: Quartz Commercial |
$634.40
|
| Rate for Payer: Quartz Medicare Advantage |
$585.60
|
| Rate for Payer: The Alliance Commercial |
$3,904.00
|
| Rate for Payer: WEA Trust Commercial |
$536.80
|
| Rate for Payer: WPS Commercial |
$722.92
|
|
|
Large black foam
|
Facility
|
IP
|
$976.00
|
|
| Hospital Charge Code |
3006912
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$478.24 |
| Max. Negotiated Rate |
$897.92 |
| Rate for Payer: Aetna Commercial |
$878.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$839.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$517.28
|
| Rate for Payer: Cash Price |
$292.80
|
| Rate for Payer: Cigna Commercial |
$897.92
|
| Rate for Payer: Health EOS Commercial |
$868.64
|
| Rate for Payer: HFN Commercial |
$897.92
|
| Rate for Payer: Multiplan Commercial |
$780.80
|
| Rate for Payer: NAPHCARE Commercial |
$585.60
|
| Rate for Payer: Preferred Network Access Commercial |
$897.92
|
| Rate for Payer: Quartz Beloit One Network |
$478.24
|
| Rate for Payer: Quartz Commercial |
$585.60
|
| Rate for Payer: WEA Trust Commercial |
$536.80
|
| Rate for Payer: WPS Commercial |
$722.92
|
|
|
LARGE BORE EXTENSION SET 32 IN 4-WAY STOPCOCK SECURE LOCK
|
Facility
|
IP
|
$44.00
|
|
| Hospital Charge Code |
2962797
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$21.56 |
| Max. Negotiated Rate |
$40.48 |
| Rate for Payer: Aetna Commercial |
$39.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$37.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$23.32
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cigna Commercial |
$40.48
|
| Rate for Payer: Health EOS Commercial |
$39.16
|
| Rate for Payer: HFN Commercial |
$40.48
|
| Rate for Payer: Multiplan Commercial |
$35.20
|
| Rate for Payer: NAPHCARE Commercial |
$26.40
|
| Rate for Payer: Preferred Network Access Commercial |
$40.48
|
| Rate for Payer: Quartz Beloit One Network |
$21.56
|
| Rate for Payer: Quartz Commercial |
$26.40
|
| Rate for Payer: WEA Trust Commercial |
$24.20
|
| Rate for Payer: WPS Commercial |
$32.59
|
|
|
LARGE BORE EXTENSION SET 32 IN 4-WAY STOPCOCK SECURE LOCK
|
Facility
|
OP
|
$44.00
|
|
| Hospital Charge Code |
2962797
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$12.32 |
| Max. Negotiated Rate |
$176.00 |
| Rate for Payer: Aetna Commercial |
$39.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$37.84
|
| Rate for Payer: Aetna Managed Medicare |
$12.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$28.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$22.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$21.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$23.32
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cigna Commercial |
$40.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$24.62
|
| Rate for Payer: Health EOS Commercial |
$39.16
|
| Rate for Payer: HFN Commercial |
$40.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$33.00
|
| Rate for Payer: Multiplan Commercial |
$35.20
|
| Rate for Payer: NAPHCARE Commercial |
$26.40
|
| Rate for Payer: Preferred Network Access Commercial |
$40.48
|
| Rate for Payer: Quartz Beloit One Network |
$21.56
|
| Rate for Payer: Quartz Commercial |
$28.60
|
| Rate for Payer: Quartz Medicare Advantage |
$26.40
|
| Rate for Payer: The Alliance Commercial |
$176.00
|
| Rate for Payer: WEA Trust Commercial |
$24.20
|
| Rate for Payer: WPS Commercial |
$32.59
|
|
|
Large cannister and gel
|
Facility
|
OP
|
$684.00
|
|
| Hospital Charge Code |
3006907
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$191.52 |
| Max. Negotiated Rate |
$2,736.00 |
| Rate for Payer: Aetna Commercial |
$615.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$588.24
|
| Rate for Payer: Aetna Managed Medicare |
$191.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$444.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$342.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$328.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$362.52
|
| Rate for Payer: Cash Price |
$205.20
|
| Rate for Payer: Cigna Commercial |
$629.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$382.77
|
| Rate for Payer: Health EOS Commercial |
$608.76
|
| Rate for Payer: HFN Commercial |
$629.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$513.00
|
| Rate for Payer: Multiplan Commercial |
$547.20
|
| Rate for Payer: NAPHCARE Commercial |
$410.40
|
| Rate for Payer: Preferred Network Access Commercial |
$629.28
|
| Rate for Payer: Quartz Beloit One Network |
$335.16
|
| Rate for Payer: Quartz Commercial |
$444.60
|
| Rate for Payer: Quartz Medicare Advantage |
$410.40
|
| Rate for Payer: The Alliance Commercial |
$2,736.00
|
| Rate for Payer: WEA Trust Commercial |
$376.20
|
| Rate for Payer: WPS Commercial |
$506.64
|
|
|
Large cannister and gel
|
Facility
|
IP
|
$684.00
|
|
| Hospital Charge Code |
3006907
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$335.16 |
| Max. Negotiated Rate |
$629.28 |
| Rate for Payer: Aetna Commercial |
$615.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$588.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$362.52
|
| Rate for Payer: Cash Price |
$205.20
|
| Rate for Payer: Cigna Commercial |
$629.28
|
| Rate for Payer: Health EOS Commercial |
$608.76
|
| Rate for Payer: HFN Commercial |
$629.28
|
| Rate for Payer: Multiplan Commercial |
$547.20
|
| Rate for Payer: NAPHCARE Commercial |
$410.40
|
| Rate for Payer: Preferred Network Access Commercial |
$629.28
|
| Rate for Payer: Quartz Beloit One Network |
$335.16
|
| Rate for Payer: Quartz Commercial |
$410.40
|
| Rate for Payer: WEA Trust Commercial |
$376.20
|
| Rate for Payer: WPS Commercial |
$506.64
|
|
|
Large white foam
|
Facility
|
OP
|
$244.00
|
|
| Hospital Charge Code |
3006910
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$68.32 |
| Max. Negotiated Rate |
$976.00 |
| Rate for Payer: Aetna Commercial |
$219.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$209.84
|
| Rate for Payer: Aetna Managed Medicare |
$68.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$158.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$122.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$117.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$129.32
|
| Rate for Payer: Cash Price |
$73.20
|
| Rate for Payer: Cigna Commercial |
$224.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$136.54
|
| Rate for Payer: Health EOS Commercial |
$217.16
|
| Rate for Payer: HFN Commercial |
$224.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$183.00
|
| Rate for Payer: Multiplan Commercial |
$195.20
|
| Rate for Payer: NAPHCARE Commercial |
$146.40
|
| Rate for Payer: Preferred Network Access Commercial |
$224.48
|
| Rate for Payer: Quartz Beloit One Network |
$119.56
|
| Rate for Payer: Quartz Commercial |
$158.60
|
| Rate for Payer: Quartz Medicare Advantage |
$146.40
|
| Rate for Payer: The Alliance Commercial |
$976.00
|
| Rate for Payer: WEA Trust Commercial |
$134.20
|
| Rate for Payer: WPS Commercial |
$180.73
|
|
|
Large white foam
|
Facility
|
IP
|
$244.00
|
|
| Hospital Charge Code |
3006910
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$119.56 |
| Max. Negotiated Rate |
$224.48 |
| Rate for Payer: Aetna Commercial |
$219.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$209.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$129.32
|
| Rate for Payer: Cash Price |
$73.20
|
| Rate for Payer: Cigna Commercial |
$224.48
|
| Rate for Payer: Health EOS Commercial |
$217.16
|
| Rate for Payer: HFN Commercial |
$224.48
|
| Rate for Payer: Multiplan Commercial |
$195.20
|
| Rate for Payer: NAPHCARE Commercial |
$146.40
|
| Rate for Payer: Preferred Network Access Commercial |
$224.48
|
| Rate for Payer: Quartz Beloit One Network |
$119.56
|
| Rate for Payer: Quartz Commercial |
$146.40
|
| Rate for Payer: WEA Trust Commercial |
$134.20
|
| Rate for Payer: WPS Commercial |
$180.73
|
|
|
Laryngeal Mask Airway Size 234
|
Facility
|
IP
|
$292.00
|
|
| Hospital Charge Code |
3101736
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$143.08 |
| Max. Negotiated Rate |
$268.64 |
| Rate for Payer: Aetna Commercial |
$262.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$251.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$154.76
|
| Rate for Payer: Cash Price |
$87.60
|
| Rate for Payer: Cigna Commercial |
$268.64
|
| Rate for Payer: Health EOS Commercial |
$259.88
|
| Rate for Payer: HFN Commercial |
$268.64
|
| Rate for Payer: Multiplan Commercial |
$233.60
|
| Rate for Payer: NAPHCARE Commercial |
$175.20
|
| Rate for Payer: Preferred Network Access Commercial |
$268.64
|
| Rate for Payer: Quartz Beloit One Network |
$143.08
|
| Rate for Payer: Quartz Commercial |
$175.20
|
| Rate for Payer: WEA Trust Commercial |
$160.60
|
| Rate for Payer: WPS Commercial |
$216.28
|
|
|
Laryngeal Mask Airway Size 234
|
Facility
|
OP
|
$292.00
|
|
| Hospital Charge Code |
3101736
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$81.76 |
| Max. Negotiated Rate |
$1,168.00 |
| Rate for Payer: Aetna Commercial |
$262.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$251.12
|
| Rate for Payer: Aetna Managed Medicare |
$81.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$189.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$146.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$140.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$154.76
|
| Rate for Payer: Cash Price |
$87.60
|
| Rate for Payer: Cigna Commercial |
$268.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$163.40
|
| Rate for Payer: Health EOS Commercial |
$259.88
|
| Rate for Payer: HFN Commercial |
$268.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$219.00
|
| Rate for Payer: Multiplan Commercial |
$233.60
|
| Rate for Payer: NAPHCARE Commercial |
$175.20
|
| Rate for Payer: Preferred Network Access Commercial |
$268.64
|
| Rate for Payer: Quartz Beloit One Network |
$143.08
|
| Rate for Payer: Quartz Commercial |
$189.80
|
| Rate for Payer: Quartz Medicare Advantage |
$175.20
|
| Rate for Payer: The Alliance Commercial |
$1,168.00
|
| Rate for Payer: WEA Trust Commercial |
$160.60
|
| Rate for Payer: WPS Commercial |
$216.28
|
|
|
LARYNGECTOMY
|
Facility
|
IP
|
$4,981.00
|
|
| Hospital Charge Code |
2960188
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,440.69 |
| Max. Negotiated Rate |
$4,582.52 |
| Rate for Payer: Aetna Commercial |
$4,482.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,283.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,639.93
|
| Rate for Payer: Cash Price |
$1,494.30
|
| Rate for Payer: Cigna Commercial |
$4,582.52
|
| Rate for Payer: Health EOS Commercial |
$4,433.09
|
| Rate for Payer: HFN Commercial |
$4,582.52
|
| Rate for Payer: Multiplan Commercial |
$3,984.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,988.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,582.52
|
| Rate for Payer: Quartz Beloit One Network |
$2,440.69
|
| Rate for Payer: Quartz Commercial |
$2,988.60
|
| Rate for Payer: WEA Trust Commercial |
$2,739.55
|
| Rate for Payer: WPS Commercial |
$3,689.43
|
|
|
LARYNGECTOMY
|
Facility
|
OP
|
$4,981.00
|
|
| Hospital Charge Code |
2960188
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,394.68 |
| Max. Negotiated Rate |
$19,924.00 |
| Rate for Payer: Aetna Commercial |
$4,482.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,283.66
|
| Rate for Payer: Aetna Managed Medicare |
$1,394.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,237.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,490.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,390.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,639.93
|
| Rate for Payer: Cash Price |
$1,494.30
|
| Rate for Payer: Cigna Commercial |
$4,582.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,787.37
|
| Rate for Payer: Health EOS Commercial |
$4,433.09
|
| Rate for Payer: HFN Commercial |
$4,582.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,735.75
|
| Rate for Payer: Multiplan Commercial |
$3,984.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,988.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,582.52
|
| Rate for Payer: Quartz Beloit One Network |
$2,440.69
|
| Rate for Payer: Quartz Commercial |
$3,237.65
|
| Rate for Payer: Quartz Medicare Advantage |
$2,988.60
|
| Rate for Payer: The Alliance Commercial |
$19,924.00
|
| Rate for Payer: WEA Trust Commercial |
$2,739.55
|
| Rate for Payer: WPS Commercial |
$3,689.43
|
|
|
Laryngoscope Blade
|
Facility
|
IP
|
$9.00
|
|
| Hospital Charge Code |
3040313
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$4.41 |
| Max. Negotiated Rate |
$8.28 |
| Rate for Payer: Aetna Commercial |
$8.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4.77
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cigna Commercial |
$8.28
|
| Rate for Payer: Health EOS Commercial |
$8.01
|
| Rate for Payer: HFN Commercial |
$8.28
|
| Rate for Payer: Multiplan Commercial |
$7.20
|
| Rate for Payer: NAPHCARE Commercial |
$5.40
|
| Rate for Payer: Preferred Network Access Commercial |
$8.28
|
| Rate for Payer: Quartz Beloit One Network |
$4.41
|
| Rate for Payer: Quartz Commercial |
$5.40
|
| Rate for Payer: WEA Trust Commercial |
$4.95
|
| Rate for Payer: WPS Commercial |
$6.67
|
|
